Esophageal perforation and neck abscess from ingested foreign bodies: treatment and outcomes

Ear, Nose & Throat Journal, Oct, 2003 by Henry Chuen Kwong Lam, John Kong Sang Woo, Charles Andrew van Hasselt

The three patients in group 1 responded well to treatment and healed without further complications. All were discharged home after 7 to 14 days. Patient 2 had his foreign body identified and removed.

The two patients in group 2 had a nasogastric tube inserted for enteral feeding while they were still under anesthesia for esophagoscopy. Both did well and were discharged within 10 days. Patient 1 had her foreign body identified and removed.

The three patients in group 3 had more difficult hospitalizations, which ranged from 23 to 28 days. Patients 3 and 8 had their foreign body identified and removed. Patient 3 required a bilateral chest drain. In patient 4, a 36-year-old woman, the iatrogenic esophageal perforation was not diagnosed until almost 24 hours following esophagoscopy. Upon diagnosis, medical treatment was immediately initiated. She had a persistent low-grade fever and leukocytosis. Serial computed tomography (CT) images of her neck and thorax on days 3 and 4 post-esophagoscopy showed a retropharyngeal abscess that had extended to the superior mediastinum; CT also identified bilateral pleural effusions. She underwent neck exploration and thoracotomy to drain the collections, and she was admitted to the intensive care unit for a brief period of postoperative mechanical ventilation and close monitoring. She was discharged on hospital day 26. Our experience suggests that patients such as those in group 3 are more likely to require surgical intervention, prolonged nutritional support, and admission to the intensive care unit.

Neck abscess. Four patients (patients 9, 10, 11, and 12) presented with a neck abscess, and they experienced a more difficult course than did most of those who had a perforation only. Patient 11 had her foreign body identified and removed. Patients 9, 10, and 12 underwent neck exploration and surgical drainage within 24 hours of their diagnosis by CT or ultrasonography. Patient 11 refused surgery and was treated conservatively. All recovered. Patient 12, a 72-year-old man, underwent a tracheostomy for airway protection and an intraoral incision for drainage of the abscess, which had extended to the level of the uvula. He was discharged on day 59; his long hospitalization was necessary because of his underlying diabetes mellitus, a postoperative chest infection, and the time required to wean him off his tracheostomy tube.

Discussion

Potentially fatal complications such as esophageal and pharyngeal perforation and deep neck abscess can develop well within 24 hours of foreign-body impaction. Pain that persists or worsens with time should be regarded as an early symptom of a serious complication. Moreover, fever and leukocytosis should not occur in uncomplicated cases of ingested foreign bodies. Pain, fever, and/or leukocytosis were present in all 12 of our patients. Thus, any patient who has ingested a foreign body and who manifests any of these features should be assumed to have a serious complication until proven otherwise.

Fish bones are the most common ingested foreign body in Hong Kong, accounting for approximately 80% of all cases. (1) In our series, 6 of the 12 patients had ingested a fish bone; the others had ingested either a chicken, pork, beef, or duck bone. It seems logical that bulky bones would be more dangerous than fish bones.